Findings Of Fact The Respondent, Colonial Palms, Inc., is licensed to operate Colonial Palms Nursing Home in Pompano Beach, Florida, as a nursing home facility, pursuant to Chapter 400, Part I, Florida Statutes, and Chapter 10D-29, Florida Administrative Code. On December 15, 1981, two representatives from the Petitioner visited the Respondent's facility in connection with its annual license survey. On this occasion the following conditions were found which were in violation of the applicable provisions of the Florida Administrative Code. Supervision of all details of nursing care to patients was not being fulfilled by the Nursing Supervisor in that: The charge nurses were not monitoring the functions of the clean and soiled utility rooms, as evidenced by mixed clean and soiled functions in the rooms. Personal luggage of patients was stored in a soiled utility room, clean foam padding was stored on a shelf in a soiled utility room. Three weeks staffing was reviewed. There was no RN on duty during the AM shift on 4 out of 21 days, 11/22, 11/28, 11/29, 12/12/81, when the average census was 74 patients. Patients' rights were violated in 4 charts reviewed in that the patients were not advised of their full rights as promulgated by the 1980 Legislature. Written consultation reports from a consulting dietitian to the Administrator were not available for review for the months of April, May, June, July, 1981. The dietary department lacked the required test kit that measures the parts per million concentration of the sanitizing solution used to sanitize the patient trays, as well as the multi use pots and pans. The hood above the cook's range, the sprinkler system, and the electric lights were soiled with a grease encrustation. Medications being administered by the nursing staff consisted of controlled and prescription drugs which were not stored in locked cabinets, but were stored on side carts exposed and accessible to all patients. The soiled utility room in the south wing was not equipped with a flushing rim clinical service sink having a wide area service trap with bedpan flushing equipment. The Respondent nursing home was given until January 15, 1982, to correct all of the conditions described above. On February 8, 1982, a follow-up visit was made to the Respondent nursing home. On this occasion the conditions described above at subparagraphs (a), (c), (d) and (f) had been corrected. The conditions described at subparagraphs (b), (e), (g) and (h) above had not been corrected. The flushing sink mentioned in subparagraph (h) above had been ordered from the nursing home's supplier on December 20, 1981. However, due to a delay in shipment, it was not received until July or August, 1982. It is now in place, as required. The remainder of the conditions which existed on February 8, 1982, are now corrected.
Recommendation From the foregoing findings of fact and conclusions of law, it is RECOMMENDED that Colonial Palms, Inc., d/b/a Colonial Palms Nursing Home, be found guilty of four separate violations on one occasion after the specified date for correction, and that Colonial Palms, Inc., be assessed an administrative fine in the amount of $400.00. THIS RECOMMENDED ORDER entered on this 30 day of November, 1982, in Tallahassee, Florida. WILLIAM B. THOMAS Hearing Officer Division of Administrative Hearings The Oakland Building 2009 Apalachee Parkway Tallahassee, Florida 32301 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 30th day of November, 1982. COPIES FURNISHED: Harold Braynon, Esquire 201 West Broward Boulevard Fort Lauderdale, Florida 33301 William L. Pace Administrator of Colonial Palms Nursing Home 51 West Sample Road Pompano Beach, Florida 33064
Recommendation Based on the foregoing facts and conclusions of law, the Hearing Officer recommends that the Board take no action against the license of Marie Novak, L.P.N. DONE and ORDERED this 16th day of December, 1976 in Tallahassee, Florida. STEPHEN F. DEAN, Hearing Officer Division of Administrative Hearings Room 530, Carlton Building Tallahassee, Florida 32304 (904) 488-9675 COPIES FURNISHED: Julius Finegold, Esquire 218 East Forsyth Street Jacksonville, Florida 32202 Robert T. Westman, Esquire Post Office Box 1888 Cocoa, Florida 32922
Findings Of Fact Defendant came on duty at Ambrosia Nursing Home at 9:00 a.m. on January 30, 1976, and was scheduled to be relieved at 3:00 p.m. During the day Defendant began showing signs of an intestinal disorder evidenced by diarrhea and vomiting. The nurse scheduled to relieve Defendant in the afternoon did not appear for duty and, despite her illness, Defendant volunteered to remain on duty for the next shift. She did advise the Director of Nursing that she was ill and would like to leave earlier than the schedule end of the shift at 11:00 p.m. The Director of Nursing advised her that she could leave at 9:00 p.m. if everything was normal. By 7:30 p.m. Defendant had checked the patients and found all were in bed and conditions normal, but her intestinal problems had not lessened. At that time she left the nursing home. The owner of the nursing home is a registered nurse and at the time occupied a room at the home. Defendant did not notify the owner that she was leaving because frequently the owner would not respond to a knock on her door. Since she had permission from the Director of Nursing to leave early, four capable aides were on duty and she was ill, Defendant departed the nursing home. No evidence was presented that the owner had been notified that Defendant had been granted permission to leave early and the inference was that she had not been so notified. The present Director of Nursing, a former Director of Nursing, and the Nursing Home, Administrator testified on behalf the Defendant. Defendant is an excellent nurse who is well liked by the patients and all members of the staff. She has always been extremely cooperative and a big asset to the nursing home. The nursing home very strongly desires that Defendant remain an employee at the home in her present position. Both directors of nursing would be well pleased to have Defendant on their services and would employ her instantly if the opportunity arose. Defendant has been licensed for nearly 24 years and this is the first time she has ever had as much as an oral admonition from a supervisor.
The Issue The issue in the case is whether the allegations of the Administrative Complaint filed by the Petitioner against the Respondent are correct and if so, what penalty should be imposed.
Findings Of Fact The Petitioner is the state agency responsible for licensure and regulation of nursing homes operating in the State of Florida. The Respondent operates a licensed nursing home at 1001 9th Street North in St. Petersburg, Florida. At approximately 7:00 p.m. on May 31, 2000, a certified nursing assistant (CNA) was feeding a resident of the nursing home an appropriate soft food meal. During the feeding, the resident began to gasp. At the time of the incident, the CNA who was feeding the resident had received training related to feeding this resident. The CNA had fed the resident previously without incident. At the time of the event, another CNA was also present in the room. An off-duty nurse walking by the resident's room saw the situation, and because the resident was seated with a food tray before her, assumed that the resident was choking. The nurse responded to the situation by performing a finger sweep of the mouth to locate food, and then performing a "Heimlich" maneuver. Because no food was located during the finger sweep or expelled after the "Heimlich" the nurse concluded that the resident was not choking. She also became aware that the resident was not breathing. The off-duty nurse lowered the resident's bed and began to perform emergency CPR. She also directed one of the CNA's present to call for the on-duty nurse. The on-duty nurse arrived shortly thereafter and began assisting with the CPR, using an "ambu-bag." Both nurses have substantial experience in nursing and as caregivers in nursing homes. There is no credible evidence that the nurses were unqualified or lacked appropriate training for their responsibilities. While performing the CPR, the off-duty nurse asked the on-duty nurse to determine whether the resident had "advance directive" information in her file. The on-duty nurse stopped using the "ambu-bag" and went to the nurse's station approximately 30 feet from the resident's room, determined that the resident had a "living will" on file, and returned to the resident's room to inform the off-duty nurse. Although there was a "living will" in the patient's file, there was no order prohibiting efforts to resuscitate the resident (commonly called a "DNR") and therefore such emergency procedures were appropriate; however, at the time the off-duty nurse initiated the CPR effort, the resident's status had not been determined. Upon the return of the on-duty nurse, the off-duty nurse stopped performing CPR and went to the nurse's station to review the paperwork in the resident's file after which she called the facility's director of nursing to report the situation. When the nurse halted her CPR effort, she had been administering "chest massage" for approximately three minutes and had gotten no response from the patient. The director of nursing told the nurse to immediately call 911 for emergency assistance. As directed, the off-duty nurse called 911, reported the information, and returned to the resident's room to resume her CPR effort. An EMT team arrived at the facility quickly after the nurse's telephone call. The EMT personnel unsuccessfully attempted to intubate the resident, and ultimately were unable to revive her. Approximately 25 minutes elapsed from initiation of efforts by the off-duty nurse to the EMT personnel determination to halt resuscitation attempts. The resident suffered from end-stage Parkinson's disease. According to the Certificate of Death, the immediate cause of death is listed as "debility of age." There is no evidence that the employees of the nursing home were the cause of or contributed to the resident's death. There is no evidence that the resident choked on food. There is no evidence that resident’s "gasping" sounds were caused by any foreign obstruction within her airway. The facility properly notified the Petitioner of the incident. The Petitioner conducted an investigation on June 2, 2000. The results of the inquiry were set forth on a form identified as a "HCFA 2567" which identifies alleged deficiencies in the Respondent's procedures and activities related to the resident's death. Deficiencies are identified on a "2567" form as "tags." Such alleged deficiencies also include a narrative description of the Petitioner's review and citation to a provision of the Florida Administrative Code rule. Insofar as relevant to this proceeding, the "2567" form identifies tags F156 and F280. TAG F156 Tag F156 alleges that the Respondent failed to "employ a system which ensured the prompt identification of residents who had formulated advance directives for purposes of implementation. The Petitioner charges that the Respondent failed to have policies and procedures for prompt identification of residents who had formulated advance directives for purposes of implementation, especially during an emergency. The Respondent maintained records of each resident's advance directive information in a red folder contained within the resident's medical file. The files were maintained at the nurse's station to facilitate immediate location and provide for a proper response by facility staff. Such record maintenance provided access to information for medical staff while maintaining each resident's rights to privacy. The evidence fails to establish that the facility's system did not provide for "prompt identification of residents who had formulated advance directives for purposes of implementation." TAG F280 Tag F280 alleges that the Respondent failed to review and revise the comprehensive interdisciplinary care plan for the resident to indicate chewing and swallowing problems. The tag also states that "the staff did not implement use of compensatory safe swallow techniques as recommended by the speech language pathologist, resulting in an emergency choking situation which compromised the life of a resident." The Petitioner charges that the Respondent failed to develop a comprehensive care plan for the resident "who was identified with chewing and swallowing problem." The evidence establishes that the interdisciplinary care plan prepared for the resident appropriately addresses the resident's potential for chewing and swallowing difficulty. The care plan identifies the specific steps to be taken in providing nutrition to the resident, including the type of diet, the positioning of the resident's body for feeding, the actual timing of food provision, and indicates that observation is required to ascertain whether the resident was aspirating or choking. The care plan set forth goals for nutrition consumption and established a deadline for achieving the goal with the resident. Tag 281 At the hearing, the Petitioner initially indicated that Tag F281 was not at issue in this proceeding. The Administrative Complaint alleges that the Respondent failed to follow the policies and procedures for obstructed airway management and did not have a system-wide policy and protocol for how nursing services respond during medical emergencies. Evidence was presented at the hearing related to this issue, which appears to be included within Tag F281. Accordingly, the following findings of fact are set forth. There is no evidence that the facility failed to maintain policies and procedures in the area of nursing services. The facility policy related to obstructed airway management is set forth in the "Nursing Policy & Procedure Manual." The types of maneuvers identified as appropriate are "abdominal thrusts" and "finger sweeps." An "abdominal thrust" is commonly referred to as a "Heimlich" maneuver. There is further no evidence that the off-duty nurse failed to follow the facility policy on obstructed airway management. The greater weight of the evidence establishes that the off-duty nurse appropriately performed both procedures on the resident prior to initiation of CPR activities. As to the provision of CPR, the off-duty nurse's CPR certification had expired at the time of the incident, but there is no evidence that she administered the CPR incorrectly during the time her efforts were made.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is recommended that the Agency for Health Care Administration enter a Final Order dismissing the Administrative Complaint filed in this case. DONE AND ENTERED this 1st day of August, 2000, in Tallahassee, Leon County, Florida. WILLIAM F. QUATTLEBAUM Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 1st day of August, 2001. COPIES FURNISHED: Michael P. Sasso, Esquire Agency for Health Care Administration 525 Mirror Lake Drive, Room 310G St. Petersburg, Florida 33701 Alfred W. Clark, Esquire 117 South Gadsden Street, Suite 201 Tallahassee, Florida 32301 Sam Power, Agency Clerk Agency for Health Care Administration 2727 Mahan Drive Fort Knox Building Three, Suite 3431 Tallahassee, Florida 32308 Julie Gallagher, General Counsel Agency for Health Care Administration 2727 Mahan Drive Fort Knox Building Three, Suite 3431 Tallahassee, Florida 32308
The Issue Whether SeaView was properly issued a conditional license and should pay an administrative fine for violation of regulations at the time of surveys conducted on February 8 and February 21, 2002.
Findings Of Fact AHCA is the state agency responsible for evaluating nursing homes in Florida pursuant to Section 400.23(7). SeaView is a licensed nursing home located in Pompano Beach, Florida. AHCA conducted a survey of SeaView on February 8, 2002, and alleged that SeaView violated the standards of Section 400.022(1)(l), and Rule 59A-4.109(1)(c)2, and 3, which relate to the obligations of a nursing home to supervise residents to assure their safety. It is undisputed that during the survey period, two residents were outside the facility, out of the company of staff, for brief periods of time. AHCA contends that these incidents demonstrate that SeaView failed to adequately supervise these residents, thereby placing them, and one other resident, “at risk of serious injury, harm, impairment or death.” AHCA also asserted that SeaView failed to adequately implement policies and procedures for investigating, reporting, and preventing allegations of possible neglect in violation of Section 400.022(1)(l) and Rule 59A-4.109(1)(c)2, by failing to report an incident to the abuse registry, failing to review a resident’s records as part of its investigation, failing to interview sufficient people as part of its investigation, and failing to take corrective action. AHCA is required to rate the severity of any deficiency identified in a survey. AHCA assigned both of the identified deficiencies a Class I rating. This means that the deficiency “has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident receiving care in a facility.” Section 400.23(8)(a). On a follow-up visit on February 21, AHCA again cited the same violations as Class I deficiencies. The charges arising out of the February 8 survey revolve primarily around a resident referred to by the parties as G. D. At the time of his admission to SeaView in September 2001, G. D. suffered from Alzheimer’s disease and alcoholic dementia. It was SeaView's practice to place cognitively impaired residents such as G. D. on the second floor of the facility. SeaView's management felt that the second floor was a more secure location for individuals like G. D. who, on account of their impairments, were considered to be at risk for attempting to exit the facility without staff knowledge or supervision, also known as "elopement." Like many Alzheimer's patients, G. D. was confused, often agitated and combative, and prone to wander. His care plan therefore employed management practices typically recommended by medical professionals for the caregivers of Alzheimer's patients, i.e. checking on him every hour, encouraging his family to bring in personal possessions, and involving him in activities of his liking, etc. G. D., like many Alzheimer's patients, was unable to fully benefit from activities. He was inclined to wander in and out of activities and to verbally interrupt them. He was at times restless and resistant to care. He was on medications which produced side effects which may have negated their beneficial effects. He tended to walk around the hallways aimlessly and try to push the alarmed doors open. Staff at SeaView, aware of these behaviors, appropriately contacted G. D.’s physician in December 2001, to obtain an order for a new psychiatric consult. This resulted in the addition of a new medication. Thereafter, nursing notes on January 7, 2002, indicated that G. D. was less aggressive and less agitated. Shortly before 8:00 p.m., on January 9, 2002, G. D. was being attended to by a certified nursing assistant (CNA) who left him briefly to attend to another resident. G. D. went to the nurse’s station, interacted with the nurse there, and left in his wheelchair. Less than ten minutes later, the CNA tried unsuccessfully to locate him. The nurse and CNA looked throughout the second floor, and when they still did not find him, went downstairs where a visitor who was just leaving motioned through a window that he was outside. The staff went out and found him tipped over on his right side, in his wheelchair, about 6-8 steps from the front door and near the bottom of concrete steps leading to a second floor exit door. He was alert and spoke, and said he was fine and that he fell from “way up top.” Staff checked G. D. and called 911. G. D. was taken by ambulance to a hospital. The neurosurgeon who was consulted documented that there was no evidence of head trauma. A CT scan was performed which did show that G. D. had old, chronic subdural hematomas (internal bleeding) on both his right and left sides, with a recent bleed into the one on the left. There is no evidence regarding when or how G. D. suffered the hematoma. The evidence did establish that hematomas can occur in the absence of significant trauma, and can even result from a strong sneeze or cough. The CT scan revealed no evidence of significant head trauma, however, such as swelling, which would be expected to be present with a severe blow. G. D. died three days later of the hematoma. It is impossible to know how G. D. was able to exit the building. At first, SeaView concluded, largely on the basis of his statement, that G. D. had fallen down the outside stairs from the second floor. SeaView staff revised its opinion on further consideration, and concluded that G. D. was somehow able to make his way down the elevator to the first floor, and then exit the building unnoticed. In reaching this conclusion, SeaView noted that the upstairs door had a 15-second delay mechanism and alarm, which had to be manually turned off by staff once activated. No alarm was heard or deactivated, and a check revealed that the mechanism was working. Shortly after the incident, staff exited the upstairs door and the alarm sounded. AHCA’s investigation determined that all doors were in working order and in compliance with all life safety code requirements. Neither the stairway nor the wheelchair exhibited any damage as would be expected from a fall down the steep, concrete stairs, and G. D. himself showed no external signs of injury except a skin tear on his arm. The evidence established that the incident occurred just prior to 8:00 p.m.; a time when staff were no longer present in the common areas, as they were putting residents to bed, and just before the front door alarm was activated for the night. From those facts, SeaView reasons that "the most likely means of exit would have been for G. D. to negotiate the elevator and exit through the front door of the facility." However, as SeaView concedes, there was no evidence that G. D. had ever used the elevator before; the idea that he was able to do so on this occasion taxes credulity, and in any event is also not supported by evidence. In charging SeaView with failing to adequately supervise G. D., AHCA denies that it is advancing a strict liability standard in cases where a patient is successful in exiting a building. Rather, AHCA contends that SeaView's failure to sufficiently supervise G. D. is proven by the fact that he was outside the building long enough to allow a fall from his wheelchair. The dispute may be one of semantics. AHCA concedes that escape is a known and common risk with dementia patients in nursing homes; that the law prohibits physical or medical restraint of residents; and there is no combination of interventions which are effective in all circumstances to prevent escape; and, most significantly, that there is no standard of practice which requires one-on-one supervision. AHCA alleged that SeaView was on notice that G. D. had escaped the facility on two prior occasions. This allegation was not supported by evidence, nor was there any evidence of prior incidents of escapes by other residents at SeaView. AHCA additionally charged that SeaView violated a duty of reporting by not calling the state's elder abuse registry to report G. D.'s escape. However, the evidence established that SeaView did in fact notify AHCA and filed required reports with the agency. Sea View's administration concluded that neglect did not exist, and thus there was no need to make the additional report to the registry. The decision was based upon the short time during which G. D. was out of view of staff, and the immediate attention given to finding him. Reasonable nursing home administrators might have erred on the side of reporting, but there is no evidence to suggest that the course followed by SeaView was outside the bounds of legitimate professional judgment. Immediately following the incident involving G. D., when SeaView's administration was of the view that he might have exited from the second floor door, SeaView had an additional alarm installed to ensure audibility. AHCA cited concerns regarding two additional patients, referred to by the parties as Residents number 3 and number 4, in the February 8 survey. As to these patients, AHCA charged deficient practice in that portions of their care plans directed to the possibility of escape did not contain a time frame for monitoring their whereabouts, and the monitoring was not documented. With respect to Resident number 3, AHCA also asserted that the approach of trying to redirect the resident was faulty, as the records reflected that often he did not respond to redirection. A surveyor also testified that she noted two times when Resident number 3 was unobserved by staff, but this testimony was effectively discredited upon cross- examination. The evidence failed to establish either the insufficiency of the patient care plans or the failure by SeaView to implement appropriate care plans. The inclusion of a time frame for monitoring does not ensure that a resident will be unable to elude staff. G. D.'s care plan, for example, contained a requirement that he be checked hourly. In practice, he was in contact with staff far more often. AHCA alleged that the monitoring of residents was not adequately documented. However, the evidence failed to establish the existence of a legal or industry standard which suggests that routine observation, or monitoring, of a resident should be documented. As a result of the February 8 survey, AHCA required SeaView to move all residents who might have been at risk for elopement to the first floor. Additionally, AHCA required SeaView to place monitors at all exits to the facility, whose sole purpose was to monitor the exit doors, all of which, except the front door, were alarmed and on a delay mechanism. AHCA also required SeaView to increase the delay mechanism from 15 to 30 seconds. SeaView implemented all these measures. However, SeaView was opposed to moving dementia and wandering residents from the second floor, which was more secluded and secure than the first floor. SeaView complied against its better judgment, because AHCA threatened to take action against the administrator’s professional license if he did not comply. At the February 21 follow-up survey visit, the surveyors originally concluded that SeaView had corrected all deficiencies. However, after SeaView’s Director of Nursing informed them that a resident referred to by the parties as Resident number 7, or A. D., had been found outside a doorway the previous day. AHCA changed its conclusion and again asserted that both deficiencies remained at a level warranting conditional licensing. On February 20 A. D. was noted to be just outside the staff entry door near the laundry room. He was outside no longer than five minutes, and the evidence suggests that the housekeeping director escorted him outside. No evidence was presented to explain why the housekeeping director escorted the resident outside, or how the facility addressed this lapse. This gap in the evidence is troubling, but what is known about the incident does not support a finding of inadequate supervision inasmuch as the exit apparently took place with the assistance of staff, and was promptly remedied. The only direct evidence concerning what supervision A. D. received came from an AHCA surveyor, who testified that while she observed A. D., and he was up and about, staff would take his hand and redirect him when he approached doorways. AHCA asserted that the care plans for A. D. and a person referred to by the parties as Resident number 2 were deficient because, while there was a direction to monitor the residents, the care plans did not include the “type, frequency, and duration” of such monitoring. Again, the evidence established that monitoring involves visual or auditory contact by staff sufficient to assure that the patient's whereabouts are accounted for at reasonable intervals appropriate to the individual's circumstances. There is no regulation, and AHCA cited to no standard, which would require such information in a care plan. Significantly, similar care plans have been reviewed and approved by AHCA in subsequent surveys at SeaView.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the AHCA enter a final order dismissing the Amended Administrative Complaint with prejudice. DONE AND ENTERED this 23rd day of October, 2002, in Tallahassee, Leon County, Florida. ___ FLORENCE SNYDER RIVAS Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 23rd day of October, 2002. COPIES FURNISHED: Lealand McCharen, Agency Clerk Agency for Healthcare Administration 2727 Mahan Drive, Mail Stop 3 Tallahassee, Florida 32308 Valda Clark Christian, General Counsel Agency for Healthcare Administration 2727 Mahan Drive Fort Knox Building, Suite 3431 Tallahassee, Florida 32308 Catherine B. Parks, Esquire Quintairos, McCumber, Prieto & Wood, P.A. 9200 South Dadeland Boulevard Miami, Florida 33156 Alba Rodriguez, Esquire Agency for Health Care Administration 8355 Northwest 53rd Street Miami, Florida 33166 Donna H. Stinson, Esquire Broad and Cassel 215 South Monroe Street, Suite 400 Post Office Drawer 11300 Tallahassee, Florida 32302
The Issue The issues for determination are: (1) whether the noncompliance as alleged during the August 30, 2001, survey and identified as Tags F324 and F242, were Class II deficiencies; (2) whether the "Conditional" licensure status, effective August 30, 2001, to September 30, 2001, based upon noncompliance is appropriate; and (3) whether a fine in the amount of $5,000 is appropriate for the cited noncompliance
Findings Of Fact Charlotte is a nursing home located at 5405 Babcock Street, Northeast, Fort Myers, Florida, with 180 residents and is duly licensed under Chapter 400, Part II, Florida Statutes. AHCA is the state agency responsible for evaluating nursing homes in Florida pursuant to Section 400.23(7), Florida Statutes. As such, in the instant case it is required to evaluate nursing homes in Florida in accordance with Section 400.23(8), Florida Statutes (2000). AHCA evaluates all Florida nursing homes at least every 15 months and assigns a rating of standard or conditional to each licensee. In addition to its regulatory duties under Florida law, AHCA is the state "survey agency," which, on behalf of the federal government, monitors nursing homes that receive Medicaid or Medicare funds. On August 27 through 30, 2001, AHCA conducted an annual survey of Charlotte's facility and alleged that there were deficiencies. These deficiencies were organized and described in a survey report by "Tags," numbered Tag F242 and Tag F324. The results of the survey were noted on an AHCA form entitled "Statement of Deficiencies and Plan of Correction." The parties refer to this form as the HCFA 2567-L or the "2567." The 2567 is the document used to charge nursing homes with deficiencies that violate applicable law. The 2567 identified each alleged deficiency by reference to a Tag number. Each Tag on the 2567 includes a narrative description of the allegations against Charlotte and cites a provision of the relevant rule or rules in the Florida Administrative Code violated by the alleged deficiency. To protect the privacy of nursing home residents, the 2567 and this Recommended Order refer to each resident by a number (i.e., Resident 24) rather than by the name of the resident. AHCA must assign a class rating of I, II or III to any deficiency that it identifies during a survey. The ratings reflect the severity of the identified deficiency, with Class I being the most severe and Class III being the least severe deficiency. There are two Tags, F242 and F324 at issue in the instant case, and, as a result of the August 2001 survey, AHCA assigned each Tag a Class II deficiency rating and issued Charlotte a "Conditional" license effective August 30, 2001. Tag F242 Tag F242 generally alleged that Charlotte failed to meet certain quality of life requirements for the residents, based on record review, group interviews, and staff interviews, and that Charlotte failed to adequately ensure that the residents have a right to choose activities that allow them to interact with members of the community outside the facility. On or about August 24, 2001, AHCA's surveyors conducted group interviews. During these interviews, 10 of 16 residents in attendance disclosed that they had previously been permitted to participate in various activities and interact with members of the community outside the facility. They were permitted to go shopping at malls, go to the movies, and go to restaurants. Amtrans transportation vans were used to transport the residents to and from their destinations. The cost of transportation was paid by Charlotte. An average of 17 to 20 residents participated in those weekly trips to dine out with other community members at the Olive Garden and other restaurants. During those trips, Charlotte would send one activity staff member for every four to six residents. The record contains no evidence that staff nurses accompanied those select few residents on their weekly outings. The outings were enjoyed by those participants; however, not every resident desired or was able to participate in this particular activity. Since 1985, outside-the-facility activities had been the facility's written policy. However, in August 2000, one year prior to the survey, Matthew Logue became Administrator of the facility and directed his newly appointed Activities Director, Debbie Francis, to discontinue facility sponsored activities outside the facility and in its stead to institute alternative activities which are all on-site functions. Those residents who requested continuation of the opportunity to go shopping at the mall or dine out with members of the community were denied their request and given the option to have food from a restaurant brought to the facility and served in-house. The alternative provided by the facility to those residents desiring to "interact with members of the community outside the facility" was for each resident to contact the social worker, activity staff member, friends or family who would agree to take them off the facility's premises. Otherwise, the facility would assist each resident to contact Dial-A-Ride, a transportation service, for their transportation. The facility's alternative resulted in a discontinuation of all its involvement in "scheduling group activities" beyond facility premises and a discontinuation of any "facility staff members" accompanying residents on any outing beyond the facility's premises. As described by its Activities Director, Charlotte's current activities policy is designed to provide for residents' "interaction with the community members outside the facility," by having facility chosen and facility scheduled activities such as: Hospice, yard sales, barbershop groups for men and beautician's day for women, musical entertainment, antique car shows, and Brownie and Girl Guides visits. These, and other similar activities, are conducted by "community residents" who are brought onto the facility premises. According to the Activities Director, Charlotte's outside activities with transportation provided by Amtrans buses were discontinued in October of 2000 because "two to three residents had been hurt while on the out trip, or on out-trips."1 Mr. Logue's stated reason for discontinuing outside activities was, "I no longer wanted to take every member of the activities department and send them with the resident group on an outing, thereby leaving the facility understaffed with activities department employees." The evidence of record does not support Mr. Logue's assumption that "every member of the facility's activities department accompanied the residents on any weekly group outings," as argued by Charlotte in its Proposed Recommended Order. Charlotte's Administrator further disclosed that financial savings for the facility was among the factors he considered when he instructed discontinuation of trips outside the facility. "The facility does not sponsor field trips and use facility money to take people outside and too many staff members were required to facilitate the outings." During a group meeting conducted by the Survey team, residents voiced their feelings and opinions about Charlotte's no longer sponsoring the field trips on a regular basis in terms of: "feels like you're in jail," "you look forward to going out," and being "hemmed in." AHCA's survey team determined, based upon the harm noted in the Federal noncompliance, that the noncompliance should be a State deficiency because the collective harm compromised resident's ability to reach or maintain their highest level of psychosocial well being, i.e. how the residents feel about themselves and their social relationships with members of the community. Charlotte's change in its activities policy in October of 2000 failed to afford each resident "self- determination and participation" and does not afford the residents the "right to choose activities and schedules" nor to "interact with members of the community outside the facility." AHCA has proved the allegations contained in Tag F242, that Charlotte failed to meet certain quality of life requirements for the residents' self-determination and participation. By the testimonies of witnesses for AHCA and Charlotte and the documentary evidence admitted, AHCA has proven by clear and convincing evidence that Charlotte denied residents the right to choose activities and schedules consistent with their interests and has failed to permit residents to interact with members of the community outside the facility. Tag F324 As to the Federal compliance requirements, AHCA alleged that Charlotte was not in compliance with certain of those requirements regarding Tag F324, for failing to ensure that each resident receives adequate supervision and assistance devices to prevent accidents. As to State licensure requirements of Sections 400.23(7) and (8), Florida Statutes (2000), and by operation of Florida Administrative Code, Rule 59A-4.1288, AHCA determined that Charlotte had failed to comply with State established rules, and under the Florida classification system, classified Tag F324 noncompliance as a Class II deficiency. Based upon Charlotte's patient record reviews and staff interviews, AHCA concluded that Charlotte had failed to adequately assess, develop and implement a plan of care to prevent Resident 24 from repeated falls and injuries. Resident 24 was admitted to Charlotte on April 10, 2001, at age 93, and died August 6, 2001, before AHCA's survey. He had a history of falls while living with his son before his admission. Resident 24's initial diagnoses upon admission included, among other findings, Coronary Artery Disease and generalized weakness, senile dementia, and contusion of the right hip. On April 11, 2001, Charlotte staff had Resident 24 evaluated by its occupational therapist. The evaluation included a basic standing assessment and a lower body assessment. Resident 24, at that time, was in a wheelchair due to his pre-admission right hip contusion injury. On April 12, 2001, two days after his admission, Resident 24 was found by staff on the floor, the result of an unobserved fall, and thus, no details of the fall are available. On April 23, 2001, Resident 24 was transferred to the "secured unit" of the facility. The Survey Team's review of Resident 24's Minimum Data Set, completed April 23, 2001, revealed that Resident 24 required limited assistance to transfer and to ambulate and its review of Resident 24's Resident Assessment Protocols (RAPs), completed on April 23, 2001, revealed that Resident 24 was "triggered" for falls. Charlotte's RAP stated that his risk for falls was primarily due to: (1) a history of falls within the past 30 days prior to his admission; (2) his unsteady gait; (3) his highly impaired vision; and (4) his senile dementia. On April 26, 2001, Charlotte developed a care plan for Resident 24 with the stated goal that the "[r]esident will have no falls with significant injury thru [sic] July 25, 2001," and identified those approaches Charlotte would take to ensure that Resident 24 would not continue falling. Resident 24's care plan included: (1) place a call light within his reach; (2) do a falls risk assessment; (3) monitor for hazards such as clutter and furniture in his path; (4) use of a "Merry Walker" for independent ambulation; (5) placing personal items within easy reach; (6) assistance with all transfers; and (7) give Resident 24 short and simple instructions. Charlotte's approach to achieving its goal was to use tab monitors at all times, to monitor him for unsafe behavior, to obtain physical and occupational therapy for strengthening, and to keep his room free from clutter. All factors considered, Charlotte's care plan was reasonable and comprehensive and contained those standard fall prevention measures normally employed for residents who have a history of falling. However, Resident 24's medical history and his repeated episodes of falling imposed upon Charlotte a requirement to document his records and to offer other assistance or assistive devices in an attempt to prevent future falls by this 93-year-old, senile resident who was known to be "triggered" for falls. Charlotte's care plan for Resident 24, considering the knowledge and experience they had with Resident 24's several falling episodes, failed to meet its stated goal. Charlotte's documentation revealed that Resident 24 did not use the call light provided to him, and he frequently refused to use the "Merry Walker" in his attempts of unaided ambulation. On June 28, 2001, his physician, Dr. Janick, ordered discontinuation of the "Merry Walker" due to his refusal to use it and the cost involved. A mobility monitor was ordered by his physician to assist in monitoring his movements. Charlotte's documentation did not indicate whether the monitor was actually placed on Resident 24 at any time or whether it had been discontinued. Notwithstanding Resident 24's refusal to cooperatively participate in his care plan activities, Charlotte conducted separate fall risk assessments after each of the three falls, which occurred on April 12, May 12, and June 17, 2001. In each of the three risk assessments conducted by Charlotte, Resident 24 scored above 17, which placed him in a Level II, high risk for falls category. After AHCA's surveyors reviewed the risk assessment form instruction requiring Charlotte to "[d]etermine risk category and initiate the appropriate care plan immediately," and considered that Resident 24's clinical record contained no notations that his initial care plan of April 23, 2001, had been revised, AHCA concluded that Charlotte was deficient. On May 13, 2001, Dr. Janick visited with Resident 24 and determined that "there was no reason for staff to change their approach to the care of Resident 24." Notwithstanding the motion monitors, on June 17, 2001, Resident 24 fell while walking unaided down a corridor. A staff member observed this incident and reported that while Resident 24 was walking (unaided by staff) he simply tripped over his own feet, fell and broke his hip. Charlotte should have provided "other assistance devices," or "one-on-one supervision," or "other (nonspecific) aids to prevent further falls," for a 93-year-old resident who had a residential history of falls and suffered with senile dementia. Charlotte did not document other assistive alternatives that could have been utilized for a person in the condition of Resident 24. AHCA has carried its burden of proof by clear and convincing evidence regarding the allegations contained in Tag F324.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that: The Agency enter a final order upholding the assignment of the Conditional licensure status for the period of August 30, 2001 through September 30, 2001, and impose an administrative fine in the amount of $2,500 for each of the two Class II deficiencies for a total administrative fine in the amount of $5,000. DONE AND ENTERED this 13th day of February, 2003, in Tallahassee, Leon County, Florida. FRED L. BUCKINE Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 13th day of February, 2003.
Findings Of Fact Based upon my observation of the witnesses and their demeanor while testifying, documentary evidence received and the entire record compiled herein, I make the following relevant factual findings. Petitioner, Stacey Health Care Centers, Inc., is licensed to operate Riverside Care Center, located at 899 Northwest Fourth Street, Miami, Florida, as a nursing home in compliance with Chapter 400, Part I, Florida Statutes, and Chapter 10D-29, Florida Administrative Code. On July 9, 1986, James A. Bavetta, assistant area supervisor, Office of Licensure and Certification, made a visit of Riverside's facility and determined that Ralph Stacey, Jr., the administrator of record, was acting in the capacity of administrator for two facilities, the subject facility and another facility in Kentucky, without having a qualified assistant administrator to act in his absence. (Respondent's Exhibit 1) Ralph L. Stacey Jr., is a licensed nursing home administrator in the States of Ohio, Kentucky and Florida. He has been licensed in Kentucky and Florida since 1974. At the time of Mr. Bavetta's visit and inspection during July, 1986, Ralph Stacey, Jr., was in Cincinnati, Ohio preparing the payroll for Stacey Health Care Centers. During this time period, Ralph Stacey, Jr., served as the administrator for the subject facility, Riverside Care Center, and another facility in Kentucky and did not have a qualified assistant administrator employed to act in his absence. However, once Mr. Bavetta issued his recommendation for sanctions, Petitioner, as part of its plan of correction, has employed a licensed administrator who is presently on staff and serves as Riverside's assistant administrator during the administrator's absence.
Recommendation Based on the foregoing findings of fact and conclusions of lawn it is RECOMMENDED: The Department of Health and Rehabilitative Services enter a Final Order imposing an administrative fine in the amount of One Thousand Dollars ($1,000.00) upon Stacey Health Care Centers- Inc., d/b/a Riverside Care Center, which amount shall be payable to Respondent within thirty (30) days after entry of Respondent's Final Order. RECOMMENDED this 18th day of September, 1987, in Tallahassee, Leon County, Florida. JAMES E. BRADWELL Hearing Officer Division of Administrative Hearings The Oakland Building 2009 Apalachee Parkway Tallahassee, Florida 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 18th day of September, 1987. COPIES FURNISHED: Kenneth S. Handmaker, Esquire MIDDLETON & REUTLINGER 2500 Brown & Williamson Tower Louisville, KY 40202-3410 Leonard T. Helfand, Esquire Office of Licensure and Certification Department of Health and Rehabilitative Services 5190 Northwest 167th Street Miami, Florida 33014 Gregory L. Coler, Secretary Department of Health and Rehabilitative Services 1323 Winewood Boulevard Tallahassee, Florida 32399-0700 R. S. Power, Esquire Agency Clerk Department of Health and Rehabilitative Services 1323 Winewood Boulevard -Building One, Room 407 Tallahassee, Florida 32399-0700
The Issue The issue is whether disciplinary action is appropriate with regard to Respondent's license as a Certified Nursing Assistant.
Findings Of Fact The Department is the state agency charged with regulating the practice of nursing pursuant to Section 20.43 and Chapters 456 and 464, Florida Statutes. Mrs. Thompson, during times pertinent, held a certificate as a Certified Nursing Assistant (C.N.A.) and was assigned license number CNA24755 by the Department. She was originally licensed October 6, 2003. At the time of the hearing she was a resident of Fountain, Florida. Lesly Buchikos (Ms. Buchikos) is a C.N.A. licensed in the State of Florida. She is also licensed in the State of New Hampshire, and has been licensed in that state since 1976. Ms. Buchikos currently lives in New Hampshire and works as a C.N.A. in a New Hampshire medical facility. She has 31 years of experience as a C.N.A. Ms. Buchikos has worked continuously as a C.N.A. since 1976. She has received specialty training in geriatrics and caring for patients suffering from Alzheimer's and related disorders. She has trained medical personnel on providing aid to elderly persons and on the rights of persons residing in nursing homes. Professionally, Ms. Buchikos has substantially more experience than Mrs. Thompson, and has undergone more training. On February 15, 2005, Mrs. Thompson and Ms. Buchikos were working together at the Community Health and Rehabilitation Center in Panama City, Florida (Community). This facility houses elderly persons. Some of the residents are mentally and physically challenged. On that day, Mrs. Thompson and Ms. Buchikos were assigned to change the soiled undergarments worn by Resident R.L. Resident R.L. was more than 70 years of age and was suffering from dementia. He was nonverbal and resisted care. He was a very difficult patient. Ms. Buchikos believes that when tending to residents, like Resident R.L., it is best to carefully explain what you wish to accomplish, before undertaking care, and to allow the resident time to respond. She believes that when the two approached Resident R.L., in the morning hours of February 15, 2005, Mrs. Thompson failed to explain their intentions toward him and that failure caused him to become agitated. According to Ms. Buchikos' testimony, Resident R.L. resisted the efforts of Mrs. Thompson. She testified that Mrs. Thompson became rough and angry with Resident R.L., cursed him, and slapped him on the left buttock. Ms. Buchikos testified that the sound emanating from the slap was so loud that it echoed through the building. Ms. Buchikos is certain that the slap was intentional and that it jolted him. She said that Mrs. Thompson used her left hand to strike him. She said this behavior upset her and that she cried. She reported this to the charge nurse, Amy Rosin, and prepared a written statement relating her allegations. Resident R.L. was unable to make a statement and has since died. Registered Nurse Jodie Mills was the nurse supervisor who was in charge of the entire facility during the hours from 11:00 p.m. February 14, 2005, to 7:00 a.m. on February 15, 2005. Early in the morning of February 15, 2005, Ms. Rosin, informed Nurse Mills of Ms. Buchikos' allegation. Based on that report he sent Mrs. Thompson home. Nurse Mills had no personal knowledge of the incident, nor, insofar as the evidence reveals, did Ms. Rosin. He noted in a statement signed by him and dated February 15, 2005, "I could not find any sign of marks on Resident R. L.'s bottom." He now works with Mrs. Thompson at Sea Breeze. He has never seen Mrs. Thompson strike anyone at Community or Sea Breeze. Registered Nurse Stan Dunn, on February 15, 2005, was a supervisor and risk manager at Community. He has 11 years of experience in the nursing field. Nurse Dunn's chain of command ran to the assistant director of nursing, who reported to the director of nursing. He was informed of the incident by Nurse Mills. Nurse Dunn investigated the incident. When he questioned Mrs. Thompson about the incident, she denied the events occurred as related by Ms. Buchikos. Nurse Dunn was intimately familiar with Resident R.L. He had personally cared for him and described him as incoherent, bigger than average, strong, and sometimes aggressive. He stated that usually two staff members were required to control him. On February 16, 2005, Nurse Dunn prepared an Initial Adverse Incident Report-Day 1 that was submitted to the Florida Agency for Health Care Administration (AHCA). This report parroted the information supplied by Ms. Buchikos. He later sent AHCA a Complete Adverse Incident Report-15 Day, which added the information that Mrs. Thompson had been formally suspended. On February 21, 2005, Nurse Dunn signed a memorandum entitled "Employee Counseling." He informed Mrs. Thompson of the results of the internal investigation into the events of February 15, 2005, and informed her that she would be terminated. She responded with threats to, "call the board" and report them. A subsequent Personnel Action Request dated February 21, 2005, effected Mrs. Thompson's termination. Nurse Dunn stated that Mrs. Thompson was terminated because the facility was not able to totally preclude that the incident did not occur and because the facility had to err on the side of caution. Mrs. Thompson stated that on the morning of February 15, 2005, it was necessary for Ms. Buchikos and her to clean Resident R.L. She said that she was holding Resident R.L. with her left arm and washing him with her right. Resident R.L. was being difficult and while holding him she had to draw back and when she did, her glove snapped and made a sound that she believes Ms. Buchikos mistook for a slap. Mrs. Thompson said that she had been in an automobile accident on December 28, 2004, and that she suffered severe injuries to her left arm and required skin grafts on it as a result. Indeed, at the hearing it was obvious that her arm was the recipient of skin grafts at some time in her life. She said that her arm was in a sling at the time of the reported incident. She stated that these injuries made it impossible for her to slap anyone with her left hand. Mrs. Thompson stated that she did not curse or otherwise speak or yell inappropriately to Resident R.L. Donna Sirk, Kevin McVay, and Joseph Mowers are licensed practical nurses with many years of experience, and they currently work with Mrs. Thompson at Sea Breeze. They have worked with her for about two years. They stated that they had never seen her curse or otherwise misbehave and stated that she was a good caregiver upon whom they could depend.
Recommendation Based upon the Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Department of Health, Board of Nursing, dismiss the Amended Administrative Complaint. DONE AND ENTERED this 24th day of April, 2007, in Tallahassee, Leon County, Florida. S HARRY L. HOOPER Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 24th day of April, 2007. COPIES FURNISHED: William F. Miller, Esquire Department of Health 4052 Bald Cypress Way, Bin C-65 Tallahassee, Florida 32399-3265 Brenda A. Thompson 21734 Clarks Road Fountain, Florida 32438 Josefina M. Tamayo, General Counsel Department of Health 4052 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399-1701 Rick Garcia, MS, RN, CCM, Executive Director Department of Health 4052 Bald Cypress Way, Bin C02 Tallahassee, Florida 32399-1701 Patricia Dittman, PhD(C), RN, CDE, Board Chair Department of Health 4052 Bald Cypress Way, Bin C02 Tallahassee, Florida 32399-1701
The Issue Whether Respondent engaged in unprofessional conduct and, if so, what penalty should be imposed on his nursing license.
Findings Of Fact The Department of Health is the state agency charged with regulating the practice of nursing pursuant to Chapter 464, Florida Statutes. Respondent, Cecil Harold Floyd, was at all times material hereto a licensed practical nurse in the State of Florida, having been issued a license numbered PN 0960631. At all times material hereto, Respondent was employed as a licensed practical nurse by the North Shore Senior Adult Community in St. Petersburg, Florida. At all times material hereto, Respondent was assigned to care for Patient M.F., a patient in the skilled nursing section of the North Shore Senior Adult Community. On February 26-27, 1996, Respondent worked as the charge nurse on the 11:00 p.m. to 7:00 a.m. shift. On February 27, 1996, at approximately 6:00 a.m., Respondent wrote in the nurse's notes that Patient M.F. was lethargic and having difficulty swallowing; that the patient's bottom dentures were out; and that the patient's tongue was over to the right side. In this entry, Respondent also noted "will continue to monitor." After Respondent completed his shift on February 27, 1996, Conchita McClory, LPN, was the charge nurse in the skilled nursing facility at North Shore Senior Adult Community. At about 8:10 a.m., Nurse McClory was called by the CNA who was attempting to wake up Patient M.F. Upon Nurse McClory's entering Patient M.F.'s room, she observed that the patient was sleeping, incontinent, and restless and that the right side of the patient's face was dropping. Based on these observations, Nurse McClory believed that Patient M.F. may have suffered a stroke and she immediately called 911. Following the 911 call, Patent M.F. was taken to Saint Anthony's Hospital in Saint Petersburg, Florida. Prior to coming to this country, Conchita McClory had been trained and worked as a registered nurse in the Philippines. However, Ms. McClory is not licensed as a registered nurse in the State of Florida. Saint Anthony's Hospital's records regarding Patient M.F. indicate that the patient had a history of multiple strokes beginning in 1986. The Department’s Administrative Complaint against Respondent included the following factual allegations, all of which were alleged to have occurred on February 27, 1996: At approximately 6:00 a.m., Respondent recorded in the nurse’s notes that Patient M.F. was lethargic and having difficulty swallowing; the patient's bottom dentures were out; and the patient's tongue was over to the right side. Respondent also noted in the nurses' notes that Patient M.F. should continue to be monitored. Patient M.F.'s roommate told Respondent that she believed that M.F. had suffered a stroke because she could not swallow and her speech was slurred. At about 8:00 a.m., Patient M.F.'s roommate went to the nurses' station and requested that a certified nurse's assistant check on M.F. Patient M.F. was found paralyzed on her left side, soaked in urine and unable to speak. There was no evidence presented to support the factual allegations referenced in paragraph 9b and 9c above and included in the Administrative Complaint.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Department of Health, Board of Nursing, enter a final order dismissing the Administrative Complaint against Respondent. DONE AND ENTERED this 6th day of October, 1999, in Tallahassee, Leon County, Florida. CAROLYN S. HOLIFIELD Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 6th day of October, 1999. COPIES FURNISHED: Howard M. Bernstein, Esquire Agency for Health Care Administration Allied Health - Medical Quality Assistance 2727 Mahan Drive, Building 3 Tallahassee, Florida 32308-5403 Cecil Harold Floyd 1680 25th Avenue, North St. Petersburg, Florida 33713-4444 Ruth Stiehl, Executive Director Board of Nursing Department of Health 4080 Woodcock Drive, Suite 202 Jacksonville, Florida 32207 Angela T. Hall, Agency Clerk Department of Health 2020 Capital Circle, Southeast, Bin A02 Tallahassee, Florida 32399-1701 Pete Peterson, General Counsel Department of Health 2020 Capital Circle, Southeast, Bin A02 Tallahassee, Florida 32399-1701
